Thornton W. Burgess Society

Brick Walk Campaign Order Form

Purchaser  ____________________________________________________________

Mailing Address ________________________________________________________

City __________________________________ State __________ Zip _____________

Home Phone ______________________Business Phone ________________________

Email __________________________________________________

SMALL BRICK   $100.00

LARGE BRICK  $250.00

To order your brick(s), fill out this order form and mail it with your payment to: Brick Walk Campaign,
Thornton W. Burgess Society, 6 Discovery Hill Road, East Sandwich, MA 02537   or fax to (508) 888-1919

If you would like us to send an acknowledgement of your contribution in honor or memory of a special
person or group, please include their name and address.

MasterCard  ___ Visa ___  Exp. Date __________ Signature____________________________